Motivational Interviewing for Substance Abuse: How It Works & What to Expect

Central Concepts of Motivational Interviewing

One of the central concepts in MI is ambivalence, which is the state of simultaneously wanting something and not wanting something, is a normal part of change and a place where many folks can get stuck for a while. Therefore, it is entirely normal to hear someone who is thinking about making a change, to make arguments for change (change talk) and against change (sustain talk), at the same time.^1,2

Another central concept in Motivational Interviewing is that the client should be the one making the argument for change, not the clinician.  If getting people who abuse substances to change was as easy as telling them about all the negative effects of drinking too much or all the problems caused by using illicit drugs, we would have no need for Alcoholics Anonymous (AA) and would have won the war on drugs a long time ago.

What happens instead, when talking about change with someone who is ambivalent (and thus holds two opposing views within themselves), is that when a helper jumps in to make the argument for change, this naturally evokes the other side of the argument. Therefore, the clinician’s goal is to get the client talking, and then to listen hard for the client’s own arguments for making a change. The spirit of MI is collaborative and nonjudgmental, so it is done for and with a person, not to them.¹

How Does Motivational Interviewing Help With Substance Abuse?

In some ways, the hallmark of addictive behavior is that the behavior often persists, despite the overwhelming damage and destruction often left in its wake. When MI was being developed to treat addictive behavior in the 1980s, some of the prevailing treatment models included Scared Straight and “therapeutic” boot camps, that used shame and guilt as the primary tools to motivate change.

In contrast, Motivational Interviewing acknowledges that people typically aren’t stuck because they don’t see the downsides of their behavior, more often they are just stuck because they feel two ways about something and because change is hard. Therefore, MI aims to create an atmosphere that is safe and empowering so the individual has the space to explore how their behavior is or is not helping them achieve what they want and value.

Therefore, in a nutshell, MI helps reduce substance abuse, by increasing an individual’s intrinsic motivation to change. Thus, MI often begins by helping someone figure out what is important to them and then exploring the ways in which their drinking or drug use is or is not getting them closer to what they want. Through this exploration, the client is hopefully convincing themselves to move one step further in the change process.

It is important to note that MI is designed to meet the client wherever they are in the change process. Therefore, unlike traditional substance abuse treatment that essentially cannot begin until the client has identified that their drinking and/or drug use is a problem, MI can even occur with someone who does not see their addictive behavior as problematic.

The stages of change, which include precontemplation (not even thinking about change), contemplation (starting to think about changing), preparation (preparing for change), action (change is being made) and maintenance (sustaining change), initially identified by Prochaska and DiClemente in the 1980s,³ has become a core concept in how to tailor motivational interviewing interventions.

Common Motivational Interviewing Techniques for Substance Abuse

The developers of Motivational Interviewing, William Miller and Stephen Rollnick, consistently emphasize that the style and spirit of Motivational Interviewing (i.e., being collaborative, accepting, respectfully curious and guiding) is the most important tool that MI can offer. Therefore, if any specific MI technique is used outside this collaborative and respectful context, it is no longer MI.

That being said, some common tools and techniques that are used in order to further the collaborative conversation about change are:

Values Card Sort

The values card sort is a structured tool for exploring values.¹⁴ This exercise can help the client clarify what is most important to them, while also helping the clinician understand the individuals’ desires and goals, which is critical for further exploration of how the addictive behavior is or is not consistent with their values.

The exercise is done as a “Q sort” wherein the client sorts a deck of value cards into three- five categories (ranging from not important to important). Next, the individual typically narrows down the list or otherwise selects their most important values. These values will be a springboard for future discussions about motivation and change.

Evoking & Highlighting Change Talk¹

A primary underlying goal of the Motivational Interviewing therapist is to listen closely for the client’s own arguments for changing (called change talk) and then to highlight, or at least reflect back to them, their own reasons for changes. Sometimes this is done through the formal exercises (such as those described below) and other times this is done through asking questions designed to evoke different kinds of change talk.

The acronym DARN summarizes some of these types of questions which aim to gather information about the client’s:

• Desire for change
• Ability to change
• Reasons for change
• Need for change

Scaling Questions¹

One of the specific tools used to evoke the need for change, is to ask the client to rate their level of perceived importance of change on a scale of 0 to 10. The value in this exercise is not necessarily found in the initial rating, but rather provides a helpful starting point to further explore the client’s reasons for changing.

One of the common follow-up questions is to ask why the client is not at a lower rating. This will naturally get them to start talking about the reasons why this change is in fact important to them, thereby providing the clinician with ample examples of change talk to highlight back.

Exploring Ambivalence: Decisional Balance^1,15,16

The decisional balance exercise is basically a more sophisticated version of a pros and cons list and is used in MI in order to help the clinician and client neutrally and thoroughly explore the advantages and disadvantages of changing substance use behavior. Using a 2×2 decision matrix, the advantages of sustaining the current behavior vs. the advantages of changing the current behavior and explored along with the disadvantages of each choice.

There will naturally be some overlap in the categories, but the repetition is designed to ensure that equal attention is given to each side of the decisional balance. Otherwise, we naturally gravitate towards almost exclusively discussing the advantages of change, which is actually correlated with less actual behavior change.

Examples of Motivational Interviewing for Substance Abuse

As previously discussed, although MI is now used for a wide range of health behavior change, the therapeutic style and technique was initially developed to treat substance abuse and addictive behavior.

Interestingly, because Motivational Interviewing has also been implemented as a “brief intervention” in many primary care settings, you may encounter Motivational Interviewing at the doctor’s office, without even knowing it.⁴ For example, an intake questionnaire may ask you to rate the importance of reducing alcohol intake or a physician may ask open-ended questions about your alcohol or drug use.

MI interventions are also used in emergency settings, such as trauma centers, in order to intervene with individuals who present with elevated blood alcohol along with their injuries.⁵ In some ways, it is more common to see MI being used outside the traditional therapy office than it is in it.

It is also common to see MI being utilized as an adjunct to traditional therapy. For example, inpatient psychiatric programs often integrate Cognitive Behavioral Therapy (CBT) and Motivational Interviewing in order to treat primary mental illness and comorbid substance use concurrently. In these instances, change in substance use has occurred even when addiction was not a primary treatment target.⁶

Part of the reason that MI shows up so many places outside traditional therapy is that the approach is so well suited for the early stages of the change process, when people are still ambivalent about changing their addictive behavior. It would be rare for someone who does not see their substance use as problematic (precontemplation) or for someone who is just starting to notice some things they don’t like about their substance use (contemplation) to seek out any form of substance abuse treatment on their own accord.

More often, in these early stages of change, folks would encounter Motivational Interviewing only at the urging of a loved one or as an adjunct to their mental traditional therapy or treatment, or in the context of a brief intervention at the doctor’s office or emergency room.

The MI approach essentially remains the same regardless of the substance of focus or if multiple substances are an issue. However, if someone does have multiple substances that are problematic for them, they can be at different stages of change for each substance, so the MI process would typically explore each substance separately.

Is Motivational Interviewing Effective for Substance Abuse?

Overall, Motivational Interviewing is effective for treatment substance abuse. Motivational Interviewing has demonstrated small to medium effect sizes with a variety of behavioral outcomes, with the evidence for treating addictive behavior being the strongest. However, there has been a fair amount of mixed results and confusing outcomes.

In the third edition of the seminal text on Motivational Interviewing, Miller and Rollnick themselves acknowledge the high degree of variability of effects across studies.¹ Part of the issue in summarizing efficacy for substance abuse is the flexible format in which MI is utilized and its focus on early stages of change. If a single session of MI encourages someone to initiate more active substance abuse treatment, this success may not be captured, if the outcome being measured is a change in substance use.

One of the early indicators of MI efficacy, came out of a large scale psychotherapy outcome study, called project MATCH.^7,8 A specific version of Motivational Interviewing was developed for this study, called Motivational Enhancement Therapy (MET), which differs from classic Motivational Interviewing only in the addition of problem feedback (the client received feedback about how their drinking compared to national averages).⁹

When compared to Cognitive Behavioral Therapy and 12-step facilitation therapy (which follows the tenants of Alcohol Anonymous), all treatment groups showed similar significant improvements in drinking outcomes. Interestingly, at subsequent one- and three-year follow-ups is when Motivational Enhancement Therapy outperformed the other treatments, but only for participants who reported high levels of anger.^7,8 This makes intuitive sense, as Motivational Interviewing is intentionally non confrontational and collaborative.

Subsequent research reviews have found that Motivational Interviewing is at least as effective as other treatments for alcohol abuse and is significantly better than no treatment.^10,11 There has been less research conducted on Motivational Interviewing for marijuana use specifically, but reviews have also shown that Motivational Interviewing is at least as effective as other treatments and significantly better than no treatment (with an increased success rate of approximately 15%).¹¹

Even less research has been conducted on other drugs, such as cocaine and heroin, but available findings similarly suggests that at a minimum, Motivational Interviewing is as good, but not better than other established drug treatments.¹¹

A recent research review examined the use of Motivational Interviewing as brief intervention for substance use in adolescents specifically.¹² The results of this analysis found that Motivational Interviewing reduced heavy alcohol use days, general alcohol use days, and general substance use-related problems, but did not reduce cannabis use.

Some practitioners conceptualize Motivational Interviewing as a helpful harm reduction tool. For instance, a Veterans Affairs clinic utilized Motivational Enhancement Therapy for Veterans with chronic pain and substance use who were being treated with Opioids.¹³ They found that this brief intervention helped the Veterans gain insight into their substance misuse, increase their motivation for change, reduced risks of overdose, and decreased substance use over time.

How to Find a Therapist Who Practices Motivational Interviewing

The Motivational Interviewing Network of Trainers (MINT) is an international organization committed to promoting high-quality Motivational Interview practice and training. The website provides helpful information regarding Motivational Interviewing, as well as a network of certified trainers. Many of these trainers also have clinics and/or practices that use Motivational Interviewing, so it is worth checking out the trainers in your local area to see if they also practice clinically.

Otherwise, just use “Motivational Interviewing” as a search term in an online directory. If you are looking for residential and/or rehab facilities, you can inquire if there are any staff trained in motivational interviewing or if there are other individual or group therapy options that incorporate Motivational Interviewing.